Combat Trauma

Combat Trauma. That war can wound minds as well as bodies was not recognized for many years. Military physicians often diagnosed combat trauma as malingering; high‐ranking officers regarded it as a threat to discipline and combat effectiveness. Some of the soldiers executed as cowards during the Civil War probably suffered from combat trauma. Not until the 1980s did the U.S. government unequivocally recognize psychic injury as a legitimate service‐related disability.

Symptoms of combat trauma have almost always been similar to those of a heart attack: involuntary trembling, exaggerated startle response (usually with respect to noises), outbursts of uncontrollable anger, nightmares, flashbacks, emotional numbing, restlessness, depression, and alcoholism. Combat trauma might persist for days or months; it can also haunt a lifetime.

Chronologically, such labels as “soldier's heart,” “shell shock,” “battle fatigue,” “Post‐Traumatic Stress Disorder” hint at the different medical and cultural assumptions of the times in which they were devised. The mid‐nineteenth‐century conviction that mental disease had an organic origin gave way to the notion that wounds to the mind have psychological causes. Recently, the pendulum has swung in the direction of biopsychological explanations for mental disorder.

Civil War surgeons were almost wholly preoccupied with amputating arms and legs, a form of higher butchery that left little time and no patience for the treatment of combat trauma—had its existence been recognized. Countless Union veterans bore psychic injuries of greater or lesser severity long into the peace—among them the jurist Oliver Wendell Holmes, Jr., and the writer Ambrose Bierce—but neither government nor society recognized this in any direct way. And in all likelihood, many ex‐soldiers themselves probably did not understand the cause of their troubles.

In the early months of World War I, combat trauma took British medical officers by surprise. At first ascribed to the concussive effect of exploding artillery rounds on the brain, “shell shock” was soon seen as an emotional response to the overwhelming and sustained life‐threatening character of modern warfare. Some medical officers prescribed “disciplinary therapy”—electric shock treatments—betraying their conviction that combat trauma was a form of malingering; others resorted to psychotherapy, the still‐novel “talking cure.”

Fully a year before the entry of the United States into the war in April 1917, the Rockefeller Foundation sponsored an inquiry by the psychiatrist Thomas Salmon into the Allies' methods of dealing with shell shock. By the time elements of the American Expeditionary Forces began landing in France, Salmon had established a psychiatric field hospital. The Americans emulated the French, treating psychiatric casualties at aid stations near the front rather than waiting, as the British did, until they had reached the rear. A medical officer's military duties tended to override his obligations to his patients. Treatment aimed at returning psychically wounded men to the front. As Sigmund Freud noted: “The physicians had to play a role somewhat like that of a machine gun behind the front line, that of driving back those who fled.”

The leading postwar veterans group, the American Legion, called for welcoming shell‐shocked veterans back into society and lobbied successfully to see them compensated, at least in part, for a war‐related disability. Within the armed forces, combat trauma was largely disregarded because medical and military authorities had come to believe that psychological testing provided an effective preventive measure against it. The prevailing degeneration theory held that mental disorders were inheritable; they were discernible at an early age. Men likely to break down in combat could be weeded out before they ever put on a uniform.

In World War II, the American armed forces swelled to enormous size; psychological testing itself was put to the test, and its premises with respect to combat trauma were found to be false. Military psychiatrists were soon convinced that any infantryman exposed to prolonged fighting would eventually break down. “There is no such thing as ‘getting used to combat,’” an official study found. If the incidence of combat trauma was likely to be highest among foot soldiers, it was by no means unknown to sailors and airmen. The crews of ships targeted by kamikazes during the Okinawa campaign (April–June 1945) sustained numerous psychiatric casualties; Joseph Heller's absurdist war novel Catch‐22 (1961) rests on the premise about what it took, in terms of a diagnosis for combat trauma, to be relieved of flying bombing raids over enemy territory.

If all wars are fearful, each is fearful in different ways. In World War I, for instance, the prevalence of shell shock was ascribed to the lethality of the western front. In the Vietnam War, however, the risk of getting killed was lower than it had been in 1917–18, but the incidence of combat trauma was higher. In Vietnam, perhaps the elusiveness of the enemy and the absence of a front inspired fears similar to those that the low odds on surviving had inspired in trench warfare. Yet in provoking combat trauma, all modern wars display common elements. The terror peculiar to undergoing sustained artillery fire, for instance, unites combat soldiers in the field at Fredericksburg in 1862 with their counterparts in the trenches of 1917, on Okinawa in 1945, and in the rice paddies of Vietnam in 1968.

Post‐Traumatic Stress Disorder (PTSD) was a post‐Vietnam creation. The outcome of the successful lobbying of Congress and the Veterans Administration by veterans' interest groups, PTSD also expressed the shifting balance of influence within the psychiatric profession: away from psychodynamic psychotherapy toward biopsychiatric, pharmacological approaches to the treatment of mental illness. So far, however, the great increase in the explanatory power of biomedical stories about combat trauma has not been accompanied by a commensurate increase in the efficacy of therapies directed against it. By altering minds, the horrific experiences of combat have reshaped lives—drastically shortening some, blighting the promise of others, ruining still others. Psychiatric casualties are implicated in what the medical anthropologist Arthur Kleinman calls “social suffering,” a web in which the woes of one person engender woes for many.[See also Aggression and Violence; Casualties; Combat, Changing Experiences of; Combat Effectiveness; Morale, Troop; Psychiatry, Military.]

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